Rehabilitation of the Knee After Medial Patellofemoral Ligament Reconstruction

Donald C. Fithian, MDa,b,c,*, Christopher M. Powers, PhD, PTd,e, Najeeb Khan, MDb,c

Rehabilitation of the extensor mechanism after patellar stabilization surgery should be based on a sound understanding of lower limb mechanics, anatomy, mechanics of the injured or repaired extensor  echanism, and a careful evaluation of the patient. Abnormal anatomic features and control deficits can, and often do, affect function of the patellofemoral joint. Current evidence suggests that patellofemoral rehabilitation should address dynamic lower extremity function, such as abnormal lower extremity motions stemming from impairments proximally (ie, hip) or distally (ie, foot), because such motions can influence the dynamic quadriceps angle (Q-angle) (Fig. 1).1 In addition, many patients with episodic patellar instability have preexisting anatomic deficiencies that may affect rehabilitation.2 Joint surface injury and degenerative articular lesions also may call for variations to the rehabilitation protocol. The purpose of this article is to provide the reader with an understanding of the current state of lower limb rehabilitation for patients who have undergone medial patellofemoral ligament (MPFL) reconstruction.


Fig. 1. A diagrammatic representation of the various potential contributions of limb malalignment and malrotation to increase Q-angle: (1) hip adduction, (2) femoral internal rotation, (3) genu valgum, (4) tibial external rotation, and (5) foot pronation. (From Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther 2003;33(11):644; with permission.)


MPFL reconstruction is a painful procedure. Severe postoperative pain can interfere with active muscle control. Pain can also impede progress with range of motion (ROM). Operating at or near the medial epicondyle of the knee often is associated with postoperative stiffness because of the higher degrees of motion of the injured soft tissues relative to the femur during knee flexion and extension. It is important to address this tendency aggressively in the early postoperative phase to avoid stiffness. Once the motion has been established, medial pain and knee stiffness caused by scarring at the femoral attachment of the graft are rare problems. Swelling, either as free intra-articular fluid (effusion) or as soft tissue edema, also can interfere with joint motion. In addition, effusion inhibits quadriceps function and may be harmful to intra-articular structures, such as articular cartilage. Both pain and swelling can be addressed in various ways. Strict elevation of the limb and limited activity in the first 1 to 2 days postoperation allow the acute inflammatory phase to pass without further perturbation by overaggressive therapy. During that time, cold therapy may be helpful, whether in the form of ice packs or commercially available cold therapy units. The use of cold therapy to reduce local pain, inflammation, and swelling is a traditional mainstay of treatment after injury.


Prolonged joint immobilization results in the loss of ground substance and dehydration of the extracellular matrix.4,5 These changes reduce the distance between fibers within the matrix, causing friction and adhesion that reduce suppleness in periarticular ligaments and cartilage. In contrast, mobilization of an injured joint is associated with enhanced collagen synthesis and more optimal fiber realignment within the tissues, reversing the processes seen with immobilization. It is not always possible to move joints immediately after surgery, but early motion is clearly desirable.6 Experience has shown that immediate, controlled ROM is not detrimental to fixation or graft development in well-positioned and securely fixed ACL grafts. Furthermore, early motion seems to be beneficial to the limb as a whole by reducing pain, promoting healthy development of cartilage and periarticular tissues, and preventing scar formation and capsular contractions.7 Therefore 1 goal of MPFL reconstruction is to use a competent graft, place it so that it will not be harmed by physiologic motion, and secure it well enough to withstand the loads associated with normal joint motion. After MPFL reconstruction, loss of full passive extension is rarely seen. However, it can be difficult to regain full flexion. In addition, failure to achieve full active extension (residual extensor lag) has been reported at short and long-term follow-up. The reasons for motion difficulties after MPFL reconstruction seem to be related to the dissection and MPFL graft location. Cyclops lesions, such as those that can physically block knee extension after ACL reconstruction, have not been reported after MPFL reconstruction. But capsular and/or infrapatellar fat pad contracture, quadriceps inhibition,  and poorly positioned grafts can lead to the complications noted earlier. An early goal of rehabilitation after MPFL reconstruction is to reestablish full knee extension. Unlike ACL reconstruction, return of passive knee extension does not guarantee full active extension. For that to occur, attention must focus on quadriceps
strengthening (see later discussion for details). Pain and swelling can be mitigated with electrical stimulation, cold therapy, and compression wraps. Passive patellar glides should be instituted as soon as tolerated, to reestablish normal passive patellar mobility within the trochlear groove in all directions (superiorly, inferiorly, medially, and laterally). Many patients have considerable apprehension because of their prior experience with patellar hypermobility, and mobilization can improve confidence in their newly acquired patella stability. Return of passive flexion can be difficult for several reasons. If the graft is not positioned properly it may tighten in flexion and tether the joint. Injury around the medial epicondyle, whether traumatic or surgical, is also associated with persistent joint stiffness if early attention is not given to full knee flexion in the rehabilitation program. The goal is to exceed 90 flexion within 6 weeks postoperatively. If that goal is achieved, then in the authors’ experience limited knee flexion will not be a problem. On the other hand, delay in achieving greater than 90 of knee flexion may allow scar tissue proliferation and formation of adhesions around the graft and within the medial knee soft tissues. Manipulation may be required to regain full knee motion if flexion past 90 is not accomplished by week 6.


Surgery of the extensor mechanism is particularly prone to cause quadriceps inhibition and dysfunction, and every effort should be made to regain quadriceps control, strength, and endurance. If the reconstruction has been performed properly, then controlled quadriceps contractions pose no threat to the graft. Quadriceps setting exercises should be started immediately after the surgery to keep the patellar tendon and infrapatellar fat pad stretched to their full length and to restore neuromuscular control. Resisted quadriceps and hamstring strengthening should be progressively used as the initial pain subsides. A strong body of levels 1 and 2 studies indicates that electrical stimulation is helpful in reducing strength loss after knee ligament surgery. Classic studies on rehabilitation after ACL reconstruction have demonstrated the value of electrical stimulation compared with voluntary contractions alone for reducing postoperative abnormalities of gait and strength. These earlier studies are supported by recent works, indicating that electrical stimulation combined with voluntary exercises is superior to voluntary exercises alone in restoring normal gait and strength. A recent review of these studies recommended neuromuscular electrical stimulation in combination with volitional contraction. Previous investigators have emphasized early application of this approach, when muscle inhibition is most pronounced, to gain maximum effect.7 Despite differences between MPFL and ACL reconstruction surgeries, there are enough similarities in postoperative neuromuscular deficiencies to suggest that strategies that are found to be successful after ACL reconstruction should be considered for those who have undergone MPFL reconstruction.


MPFL reconstruction, whether performed alone or in combination with osteotomy of the tibial tubercle, is not affected by axial loading of the joint. For this reason, there should be no a priori reason to limit weight bearing after surgery as long as axial rotation of the limb is not allowed. The limb should be splinted in a brace during weight-bearing activities for 4 to 6 weeks postoperatively or at least until limb control is sufficient to prevent falls and rotational stress on the knee. Early weight bearing should follow a gradual progression from full protection with a rigid brace locked at full extension to an unlocked brace with crutches. Gradual increase to full weight bearing should be permitted as quadriceps strength is restored. Care should be taken during weight bearing to prevent dynamic knee valgus and hip internal rotation, which can cause abnormal loads on the healing graft. This is important because many patients with patellofemoral disorders have preexisting deficiencies in proximal limb control that can contribute to these motions. When postoperative quadriceps weakness and neuromuscular inhibition is superimposed on poor proximal control, unprotected weight bearing can result in abnormal forces on the healing graft. A frequently cited study of graft healing in dogs suggested that 8 to 12 weeks are required for tendon-to-bone healing within tunnels to support graft tension without the risk of slippage.15 For this reason, care is needed to avoid any rotational activity during the first 3 months postoperatively. Unprotected single-leg stance on the operated knee should be avoided until satisfactory proximal limb control has been achieved. The postoperative brace should be removed for resisted flexion and extension strengthening as well as other controlled rehabilitative exercises that do not cause knee valgus or axial rotational torque that would jeopardize the graft fixation. Treatment to enhance proximal control can be started preoperatively and then immediately after surgery. Postoperatively, patients should perform non–weight bearing exercises targeting the hip abductors, external rotators, and extensors. When performing strengthening exercises for the gluteus medius, the patient must take care to minimize the contribution of the tensor fascia lata, because contraction of this muscle contributes to medial rotation of the lower extremity. Once the patient is able to isolate the proximal muscles of interest in non–weight bearing exercises, progression to weight-bearing activities can begin. Facilitation of normal gait is an essential component of the overall treatment plan. This is particularly important for the returning athlete (especially runners), in whom even a slight gait deviation can be compounded by repetitive loading. The clinician should pay particular attention to the quadriceps avoidance gait pattern (walking with the knee extended or hyperextended). Because knee flexion during weight acceptance is critical for shock absorption,16 this key function must be restored to prevent the deleterious effects of high-impact tibiofemoral joint loading. The primary causes of quadriceps avoidance are pain, effusion, and quadriceps muscle weakness. As these impairments are addressed in other aspects of treatment, the clinician should keep in mind that resolution of symptoms may not readily translate into a normalized gait pattern. This is particularly evident in a patient with long-term pain and dysfunction. Movement patterns can be learned, and the patient may need to be reeducated with respect to key gait deficiencies. Electromyographic (EMG) biofeedback can be an effective tool for this purpose (Fig. 2).


Fig. 2. EMG biofeedback can be used to facilitate quadriceps recruitment during functional tasks. (Reproduced from Powers CM, Souza RB, Fulkerson JP. Patellofemoral joint. In: Magee DJ, Zachazewski JE, Quillen WS, editors. Pathology and intervention in musculoskeletal rehabilitation. St. Louis (MO): Saunders Elsevier; 2008. p. 628; with permission.)


Functional training of the limb can begin in earnest 3 months after surgery. At this time, the patient should be introduced to the concept of neutral lower extremity alignment. This involves alignment of the lower extremity such that the anterior superior iliac spine and knee remain positioned over the second toe, with the hip positioned neutrally (Fig. 3). Postural alignment and symmetric strengthening should be emphasized during all exercises (see Fig. 3). If the patient has a difficult time maintaining proper lower extremity alignment during initial weight-bearing exercises, femoral strapping can be used to provide kinesthetic feedback and to augment muscular control and proprioception (Fig. 4). Also, taping or bracing of the patellofemoral joint may be done if pain is limiting the patient’s ability to engage in a meaningful weight-bearing exercise program. Partial squats, which may have been started already in a controlled environment under supervision, can be advanced to incorporate a BOSU ball (BOSU Fitness LLC, San Diego, CA, USA) or a similar device to facilitate proximal control. Again many patients may exhibit abnormal movements or postures during training tasks. As such close supervision may be necessary to ensure proper execution. Once the patient understands the proper movement and goal of the task, continued performance in front of a mirror provides useful feedback. As strength, control, and balance progress, single-leg activities may be initiated. This is the final step before returning to full unrestricted activity. Considering that most patients are conditioned by their preoperative apprehension caused by patellar instability and that some patients may not have performed single-leg squats on the operated leg for years before the operation, the patient may not progress to this stage before 5 to 6 months after the reconstruction. In any case, rehabilitation from this point onward requires careful assessment and progressive development of proximal lower limb control.


Fig. 3. Weight-bearing activities (such as the single-leg squat shown in the figure) should be done with particular attention to proper alignment of the pelvis, hip, knee, and ankle. (Reproduced from Powers CM, Souza RB, Fulkerson JP. Patellofemoral joint. In: Magee DJ, Zachazewski JE, Quillen WS, editors. Pathology and intervention in musculoskeletal rehabilitation. St. Louis (MO): Saunders Elsevier; 2008. p. 631; with permission.)


Patients should be encouraged to return to their sport or activity gradually once they can achieve satisfactory single limb dynamic control. With competitive or recreational athletes who will be returning to full participation, plyometric training (ie, jump training) should be considered during this phase of the rehabilitation program. As patients, particularly athletes, return to sport activities, repetitive forces applied through the knee joint must be controlled adequately to allow continued healing of the injured or repaired tissues. During an extended time of recovery, such as following knee extensor mechanism surgery, quadriceps and hip muscle strength should be maintained (ie, maintenance program) through careful application of resistive exercises. Experience has shown that patients can expect to return to unrestricted activities by 6 months to 1 year postoperatively.


Artigo original:

Musculatura Abdominal

A musculatura abdominal profunda é essencial para termos uma boa estabilidade lombopelvica. Quando não acionamos da forma correta o transverso abdominal, temos uma reação em cadeia:

  • Instabilidade de tronco
  • Flexão de quadril instável
  • Psoas traciona anteriormente as vértebras lombares
  • Anteversão pélvica e hiper lordose lombar

Essa instabilidade nos leva à ações musculares ineficientes e aumenta a predisposição ao desenvolvimentos de algumas patologias como: hérnia discal e lombalgia.


The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains

Natalie Collins, Pamela Teys, Bill Vicenzino*
Department of Physiotherapy, The University of Queensland, St. Lucia, Brisbane, QLD 4072, Australia
Received 17 December 2002; received in revised form 25 July 2003; accepted 21 August 2003


The lateral ligament complex of the ankle, described as the body’s ‘‘most frequently injured single structure’’ (Garrick, 1977), is mechanically vulnerable to sprain injury. At extremes of plantarflexion and inversion, influenced by the shorter medial aspect of the ankle mortise, the relatively weak anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are prone to varying grades of rupture, often via minimal force (Hockenbury and Sammarco, 2001). Immediate inflammatory processes produce acute anterolateral pain and oedema, with avoidance of movement and weight bearing (Wolfe et al., 2001). Subsequent losses of joint range, particularly dorsiflexion, and muscle strength results in significant gait dysfunction. Recent data from our laboratory highlights the presence of a dorsiflexion deficit not only in the acute stage, but also in the subacute stage (Yang and Vicenzino, 2002). Early physiotherapy intervention consists of rest, ice, compression, elevation (RICE) and electrotherapy modalities to control inflammation, as well as manipulative therapy and therapeutic exercise techniques to address impairments of movement and strength (Wolfe et al., 2001; Hockenbury and Sammarco, 2001). Green et al. (2001) investigated the impact of combining nonweight-bearing talocrural anteroposterior (AP) passive mobilisations, believed to restore dorsiflexion range, with the RICE protocol in the treatment of acute ankle sprains. The experimental group ðn ¼ 19Þ demonstrated a more rapid improvement in pain-free dorsiflexion and function than the control group ðn ¼ 19Þ who were treated solely with RICE. This provides important evidence substantiating the role of passive joint mobilizations in an acutely injured population. The mobilization with movement (MWM) treatment approach for improving dorsiflexion post-ankle sprain combines a relative posteroanterior glide of the tibia on talus (or a relative anteroposterior glide of the talus on the tibia) with active dorsiflexion movements, preferentially in weight bearing (Mulligan, 1999). Claims of rapid restoration of pain-free movement are associated with MWM techniques generally (Mulligan, 1993, 1999; Exelby, 1996). Through examination of the effects of MWM on ankle dorsiflexion in asymptomatic mildly restricted ankle joints, Vicenzino et al. (2001) found that both the weight bearing and non-weightbearing variations of the dorsiflexion MWM technique produced significant gains in dorsiflexion range. However, weight-bearing treatment techniques are widely believed to be superior to non-weight-bearing techniques, as they replicate aspects of functional activities (Mulligan, 1999). Acute ankle sprains, whilst having marked reduction in dorsiflexion range of motion, are frequently painful in full weight bearing, and weightbearing techniques are not clinically indicated. The subacute ankle sprain is characterized by significant residual deficits in dorsiflexion (Yang and Vicenzino, 2002) and the capacity to fully weight bear, making it a good model on which to study the initial effects of weight-bearing MWM on dorsiflexion. The mechanism of action of manipulative therapy has been the focus of several reports in recent times, however spinal manipulative therapy appears to be the common subject of research. A synopsis of current evidence for the initial mechanism of action of manipulative therapy indicates in part a neurophysiological basis (Vicenzino et al., 1996, 1998, 2000). Manipulative therapy treatment techniques studied have exhibited non-opioid hypoalgesia to mechanical but not thermal pain stimuli (Vicenzino et al., 1995, 1998). The primary objective of this study was to test the hypothesis that application of Mulligan’s MWM technique for talocrural dorsiflexion to subacute lateral ankle sprains produces an initial dorsiflexion gain, and simultaneously produces a mechanical but not thermal hypoalgesia.


The double-blind randomized controlled trial incorporated repeated measures into a cross over design, in which each participant served as their own control.

Participants: Sixteen participants, eight males and eight females aged 18–50 (average 28.25 years and standard deviation 9.33 years), were recruited through the University Physiotherapy Clinic, local physiotherapy practices and sporting clubs, and University advertising. The primary criterion for inclusion was a grade II ankle lateral ligament sprain that was sustained on average 40 days (724 days standard deviation) prior to testing. We defined this sprain as ‘‘an incomplete tear of the ligament with mild laxity and instability (and) slight reduction in functiony’’ (Safran et al., 1999); A minimum pain-free dorsiflexion asymmetry of 10mm on weight-bearing measure (Vicenzino et al., 2001), anterolateral ankle tenderness, and full pain free weightbearing capacity were also required. Acute ankle sprains were excluded due to the potential for exacerbation of pain with repeated testing on the outcome measures. Exclusion also occurred if fracture or intra-articular ankle effusion were clinically detectable, or if there was a recent history of other lower limb or lumbar spine conditions. Physiotherapists and physiotherapy students were excluded to remove a potential source of bias from the participants. Ethical clearance was obtained from the relevant Institution Review Board for ethics at the University of Queensland, and all participants provided informed consent.

Outcome measures
Dorsiflexion: Weight-bearing dorsiflexion (DF), found to have excellent inter- and intra-rater reliability (Bennel et al., 1998), was measured using the knee-to-wall principle. The participant stood in front of a wall, with the test foot’s second toe and midline of the heel and knee maintained in a plane perpendicular to the wall. The participant slowly lunged forward into talocrural dorsiflexion until the knee contacted the wall, and progressively moved the foot back to the point where the knee could just touch the wall with the heel sustained on the ground. This represented end of range dorsiflexion, and the distance between the wall and second toe was measured in millimetres using a tape measure. The examiner ensured maintenance of heel contact via verbal instructions and manual contact with the calcaneum. Vicenzino et al. (2001) found this measure to be more sensitive in detecting treatment effects than an angular weight-bearing measure and a non-weight-bearing measure.

Pain: Quantitative measures of pain were obtained via pressure and thermal pain threshold. Pressure algometry, which has demonstrated reliability (Pontinen, 1988), was used to measure pressure pain threshold (PPT) at three lower limb sites:over the proximal third of the tibialis anterior muscle belly; (2) directly distal to the lateral malleolus over the CFL; directly anterior to the lateral malleolus over the ATFL. A digital pressure algometer (Somedic AB, Farsta, Sweden) was used to measure the pressure applied to the test site by a rubbertipped probe (area 1 cm2), which was positioned perpendicular to the skin. The pressure was applied at a rate of 40 kPa/s. Activation of a button by the participant at the precise moment that the pressure sensation changed to one of pain and pressure, signalled cessation of pressure application, and froze the measurement onscreen for manual recording. The Thermotest System (Somedic AB, Farsta, Sweden) measured hot and cold thermal pain threshold (TPT). A rectangular contact thermode was manually positioned over two sites: (i) the proximal third of the tibialis anterior muscle belly, and (ii) over the ATFL, extending from the anteroinferior border of the lateral malleolus toward the toes at an angle that allowed maximal contact with the foot contours. The hot or cold stimuli were increased at a rate of 1ºC/s from a baseline of 30ºC. Participants pressed a button at the precise moment that the thermal sensation changed to one of pain and heat for heat pain threshold, and one of pain and cold for cold pain threshold. At this point, stimulation ceased and the temperature reached was manually recorded. Automatic cut-off points of 52ºC and 2.5ºC were adopted to ensure safe stimulus application.

Treatment conditions: Three treatment conditions, consisting of MWM for dorsiflexion, placebo and a no-treatment control, were studied. During the treatment condition, the dorsiflexion MWM technique was performed on the symptomatic talocrural joint, as described by Mulligan (1999). With the participant in relaxed stance on a bench, a nonelastic seatbelt was placed around the distal tibia and fibula and the therapist’s pelvis, with foam cushioning the Achilles tendon. A backward translation by the therapist imparted tension on the seatbelt and a posteroanterior tibial glide, while the talus and forefoot were fixated with the webspace of one hand close to the anterior joint line. The other hand was positioned anteriorly over the proximal tibia and fibula to direct the knee over the second and third toes to maintain a consistent alignment of the distal leg and foot. The glide was sustained during slow active dorsiflexion to end of pain-free range, with the seatbelt kept perpendicular to the long axis of the tibia throughout movement, and released after return to the starting position. Three sets of 10 repetitions were applied, with one minute between sets (Exelby, 1996). Pain experienced during treatment resulted in immediate cessation of the technique and exclusion from the study. The placebo condition replicated the treatment condition, with the following exceptions. The seatbelt was placed over the calcaneum, and only minimal tension imparted to take up the slack. One hand remained on the proximal tibia and fibula, however the other hand was positioned across the metatarsal bases. Instructions were given to produce a small inner range dorsiflexion while the seatbelt was maintained perpendicular to the tibia. An identical number of repetitions, sets and interval period were used. In the control condition, the participant assumed the same relaxed stance position as for treatment and placebo, and maintained this for five minutes. No manual contact occurred between the therapist and participant.

Procedure: A preliminary session, during which a clinical examination and the three outcome measures were performed on both ankles, was conducted initially to determine the participant’s suitability for inclusion. This session also served to familiarize participants with testing procedures. Suitable participants returned for three testing sessions within one week of the initial appointment. These were scheduled at similar times of the day to prevent diurnal variations in joint range and pain, and allow a 24-h interval for wash-out of any treatment effects. Testing was conducted in an environment-controlled laboratory, with constant temperature and humidity. Each testing session began with the asymptomatic then symptomatic ankles undergoing each of the three outcome measures. With the participant in side lying, a splint was applied to the testing ankle to maintain a standardized 10 of plantarflexion. PPT and TPT measures were then conducted in an order randomized by the toss of a coin, followed by weight-bearing dorsiflexion. Three repetitions of each measure were taken. The examiner then left the laboratory while the therapist then entered and applied one of the treatment conditions (MWM, placebo, control) to the symptomatic ankle. Following treatment, outcome measures were repeated on the symptomatic ankle by the examiner to evaluate the effect of treatment. This  procedure facilitated blinding of the examiner. The participant was unaware of the aim of the study and which treatment condition was under investigation. Over the 3 days of involvement in the primary study, each participant experienced all three treatment conditions in a randomised order as determined by the roll of a dice by the therapist.



Acceptable intrarater reliability was determined through analysis of pre-treatment data from the three testing sessions. The intraclass correlation coefficient (ICC) and standard error of measurement (SEM) data for the pain measures are presented in Table 1. The ICC and SEM for the dorsiflexion measure were 0.99 and 3.50 mm, respectively. The ICC for the pain measures ranged from 0.95 to 0.99. The SEM for pressure pain threshold ranged from 5.57 to 12.00 kPa, and the thermal pain threshold SEM ranged from 0.22 to 0.74C. Note that both the size of the error (SEM) and the ICC are indicative of reliable measures.

Data management and analysis

Two independent variables were incorporated into the research design; TREATMENT (MWM, placebo, control), and TIME of application (pre- and post-intervention). Three dependent variables, measures of pressure pain threshold (PPT), thermal pain threshold (TPT) and dorsiflexion (DF), were evaluated. Prior to analysis, triplicate DF, PPT and TPT data were averaged. Data pertaining to two of the participants were excluded from analysis; subject 4 who had a post-testing MRI that revealed an osteochondral lesion of the talus and ankle joint effusion, and subject 7 who experienced pain during the MWM technique. Pre-experiment differences between sides (symptomatic–
asymptomatic) were evaluated by paired t-tests ða ¼ 0:05Þ: A two-factor analysis of variance (ANOVA) was then performed on each of the three dependent variables to test the hypothesis that MWM produced changes in excess of placebo and control from pre- to postapplication. Any significant interaction effects were followed up with tests of simple effects. Post hoc tests of main effects were performed in the absence of an interaction. A Bonferroni adjustment ðaadjusted ¼ 0:05=3 ¼ 0:017Þ was used to interpret results of the pair wise tests of simple effects and to adjust for any type I error resulting from multiple comparisons.


Pre-experiment deficits in outcome measures: Pre-experiment values for dorsiflexion and pain measures of the affected and unaffected ankles are displayed in Table 2. Statistical analysis of side-to-side differences revealed a deficit only for dorsiflexion (DF) (t ¼ 5:689; Po0:001) and pressure pain threshold over the anterior talofibular ligament (PPT ATFL) (t ¼ 2:570; P ¼ 0:025). No such deficits in thermal pain threshold (TPT) were found.

Primary study
Dorsiflexion: A significant interaction time by condition effect for the dorsiflexion outcome measure was detected by the ANOVA (Fð2;26Þ ¼ 7:817; P ¼ 0:002). The interaction plot is shown in Fig. 2. Post hoc analysis revealed a significant treatment effect for dorsiflexion from pre- to post-application (t ¼ 2:870; P ¼ 0:013). The post hoc analysis for the pre- and post-application data showed no significant differences between the placebo (t ¼ 1:343; P ¼ 0:202) and control (t ¼ 1:324; P ¼ 0:208) conditions. Table 3 presents the dorsiflexion data.

figure2 table2 table3 table4

Pain: The data for pain thresholds for pressure, cold and heat stimuli are expressed as mean and standard deviation in Table 4. Statistical analysis of the pain related data revealed no interaction effects (see Fig. 2 for plots). However, there were main effects for time for PPT ATFL (Fð1;13Þ ¼ 6:401; P ¼ 0:025) and PPT TA (Fð1;13Þ ¼ 9:17; P ¼ 0:010). Post hoc tests of simple effects demonstrated significant pre- to post-differences for PPT ATFL in the placebo condition (t ¼ 2:774; P ¼ 0:016) (Fig. 3), but no significant change in PPT TA. No significant time or condition effects were evident for PPT CFL, or the TPT measures.


Application of the dorsiflexion mobilization with movement (MWM) technique to patients with subacute lateral ankle sprains produced a significant immediate improvement in dorsiflexion, but had no significant initial effect on mechanical and thermal pain threshold measures. This dorsiflexion gain following manipulative therapy parallels findings by Green et al. (2001) in acute ankle injuries, and Vicenzino and colleagues’ (2001) study of asymptomatic minimally restricted ankles. Current and previous research findings suggest that the predominant mechanism of action for the dorsiflexion MWM technique is most likely mechanical, rather than a direct hypoalgesic effect. An excessive anterior displacement of the talus is believed to occur during plantarflexion/inversion injury and persist with residual laxity of the anterior talofibular ligament (ATFL) (Mulligan, 1999). Denegar et al. (2002) reported increased ATFL laxity and restricted posterior talar glide in twelve athletes who had sustained an ankle sprain 6 months earlier and had since returned to sport. The clinical rationale given for the anteroposterior glide component of the weight-bearing dorsiflexion MWM technique is to reduce any residual anterior displacement of the talus (Mulligan, 1999). Mulligan (1993, 1999) proposed that correction of the restricted posterior glide, via repetitions of DF with a sustained anteroposterior talar mobilization (mechanically similar to posteroanterior tibial glide on talus), restores the normal joint kinematics even after release of the glide. The mechanism by which this occurs in the presence of ATFL laxity requires further examination. Despite the presence of a reduction in pressure pain threshold (PPT) over the ATFL, the MWM technique did not produce a significant change in local PPT in the initial post-treatment period. The dorsiflexion MWM’s mechanism of action therefore appears to be mechanical, and not directly via changes in the pain system. The conduct of further research is required to identify a precise mechanism. While small but non-significant increases in pressure pain threshold occurred following treatment and control application, it was the placebo condition that produced a statistically significant improvement in pressure pain threshold over the ATFL. It is possible that the gentle inner range dorsiflexion movement performed during the placebo condition was more successful at altering the local pathophysiology peripherally at the ankle or via central neurophysiological mechanisms than the sustained end of range glide and larger range movement of the MWM technique. The application of small amplitude accessory glides of joints in an acute and painful state has been previously advocated (Maitland, 1985) and their benefits in the subacute population requires further investigation. The reasonably small sample size should also be considered to have influenced the results of the statistical analysis. It is possible that the pain measures have a lower sensitivity to change than the dorsiflexion measure, yet the significant dorsiflexion improvement seen post-treatment indicates that range gains are the predominant effect. In addition the failure to elicit prestudy deficits in thermal pain thresholds most likely lessened the likelihood of detecting a change with treatment. Research using a larger sample size and possibly acute ankle sprains with deficits in thermal
pain, should they exist, may reveal differences not detected in this study.


Mulligan’s dorsiflexion mobilization with movement technique significantly increases talocrural dorsiflexion initially after application in subacute ankle sprains. The absence of hypoalgesia post-application suggests a predominant mechanical rather than hypoalgesic effect behind the technique’s success. Further research using a larger sample is required to determine the exact mechanism behind this.

Hydrotherapy on exercise capacity, muscle strength and quality of life in patients with heart failure: A meta-analysis

Mansueto Gomes Neto, Cristiano Sena Conceição, Fabio Luciano Arcanjo de Jesus , Vitor Oliveira Carvalho

Heart failure (HF) is clinically characterized by exercise intolerance, poor health related quality of life (HRQOL) and high mortality. Exercise training is a well-established method to improve exercise intolerance and to restore HRQOL in patients with HF. However, the most efficient modality is unknown. In this context, hydrotherapy (i.e. exercise in warm water) has been proposed as an alternative tool in the rehabilitation of patients with HF. There is no meta-analysis of the efficacy of this intervention in HF patients. The aim of this systematic review with meta-analysis was to analyze the published randomized controlled trials (RCTs) that investigated the effects of hydrotherapy on exercise capacity and HRQOL in HF patients. This review was planned and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched for references on MEDLINE, EMBASE, CINAHL, PEDro, and the Cochrane Library up to May 2014 without language restrictions. This systematic review included all RCTs that studied the effects of hydrotherapy in aerobic capacity, muscle strength and/or HRQOL of the HF patients. Two authors independently evaluated and extracted data from the published reports. Methodological quality was also independently assessed by two researchers. Studies were scored on the PEDro scale a useful tool for assessing the quality of physical therapy trials based on a Delphi list that consisted of 11 items with a score range of 0 to 10.



Pooled-effect estimates were obtained by comparing the least square mean percentage change from baseline to study end for each group. Two comparisons were made: hydrotherapy versus control group (non exercise) and hydrotherapy versus aerobic exercise group. All analyses were conducted using Review Manager Version 5.0 (Cochrane Collaboration). Six papers met the eligibility criteria. Fig. 1 shows the PRISMA flow diagram of studies in this review. The results of the assessment of the PEDro scale are presented individually in Table 1. The final sample size for the selected studies ranged from 14 to 25 and mean age of participants ranged from 51 to 75 years. All studies analyzed in this review included outpatients with documented HF and New York Heart Association (NYHA) classes II–III. Table 2 summarizes the characteristics. Hydrotherapy was considered as aerobic and strength exercises in warm water and the duration of the programs ranged from 3 to 24 weeks. Regarding the time of the session, there was a variation from 30  to 90 minutes. The frequency of sessions was three times per week in three studies and five times per week in others. Four studies assessed peak VO2 as an outcome, two compared hydrotherapy versus no exercise [10,11] and two hydrotherapy versus conventional aerobic exercise in land. The meta-analyses showed a significant improvement in peak VO2 of 2.97 mL·kg−1 ·min−1 (95% CI: 1.99, 3.94, N = 42) for participants in the hydrotherapy group compared with the no exercise group (Fig. 2A). A non significant change in peak VO2 of −0.66 mL·kg−1 ·min−1 (95% CI: −2.05, 0.72, N = 48) was found for participants in the hydrotherapy group compared with conventional aerobic exercises (Fig. 2B). Three studies assessed the 6-minute walk test (6WMT) as an outcome [10,11,14], two compared hydrotherapy versus no exercise and one hydrotherapy versus aerobic exercises in land. Significant improvements were found when comparing hydrotherapy with no exercise controls. The meta-analyses showed (Fig. 3) a significant improvement in 6WMT of 43.8 m (95% CI: 7.36, 80.16, N = 42) for participants in the hydrotherapy group compared with the no exercise group. Three studies assessed muscle strength as an outcome, two compared hydrotherapy versus no exercise and one hydrotherapy versus aerobic exercise in land. Significant improvements were found when comparing hydrotherapy with no exercise controls. The meta-analyses showed (Fig. 4) a significant improvement in muscle strength of 23.7 Nm (95% CI: 4.49, 42.89, N = 42) for participants in the hydrotherapy group compared with the no exercise group. Two studies measured HRQOL. The meta-analyses showed non significant improvement in HRQOL of −4.5 (95% CI: −14.40, 5.49, N = 42) for participants in the hydrotherapy group compared with the no exercise group (Fig. 5). Meta-analysis demonstrated a significant difference in peak VO2, distance in the six-minute walking test, muscle strength and DBP between patients with HF submitted to hydrotherapy and controls. Moreover, hydrotherapy was as efficient as conventional aerobic exercise in land for peak VO2. It is now known that cardiac function actually improves during water immersion due to the increase in early diastolic filling and decrease in heart rate, resulting in improvements in stroke volume and ejection fraction. These data created a positive scenario to discuss hydrotherapy as a potential tool in cardiovascular rehabilitation. This systematic review with meta-analysis is important because it analyzes the hydrotherapy as a potential co-adjutant modality in the rehabilitation of patients with HF. The mean of peak VO2 in the analyzed studies was 17.05 at the beginning and 18.3 mL·kg−1 ·min−1 at the end of the intervention. It has been demonstrated that improvements above 10% after a cardiovascular rehabilitation program represent a good prognosis in patients with HF. It has also been demonstrated that a minimum VO2 peak of 15 mL·kg−1 ·min−1 in women and 18 mL·kg−1 ·min−1 in men aged 55–86 years seems to be necessary for full and independent living. Thus the improvement generated by the hydrotherapy program can contribute to those patients with CHF to have better conditions to carry out their everyday activities.




Quadriceps mass and strength are related to maximal exercise capacity in HF. Moreover, changes in muscle performance with exercise training have been demonstrated to be related to changes in physical function and quality of life. In the present systematic review, our meta-analysis demonstrated a significant difference in muscle strength between patients with HF submitted to hydrotherapy and sedentary controls. Despite the fact that hydrotherapy was shown to be efficient in improving peak VO2 and muscle strength, it is not possible to conclude about the benefits of hydrotherapy compared to no exercise in HRQOL. Considering the available data, our meta-analysis showed that hydrotherapy was efficient to improve exercise capacity in patients with HF. Well controlled RCTs are needed to understand the potential bene- fits of hydrotherapy in patients with HF.

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Idosos com osteoartrite de joelho obesos e não obesos

Durante o processo de envelhecimento, ocorrem perdas funcionais que se acentuam devido à falta de atividade do sistema neuromuscular e à redução da força muscular e do condicionamento físico. Além da redução da funcionalidade, o idoso perde de maneira mais acentuada a capacidade de reter água e de produzir proteoglicanos, o que causa alterações degenerativas articulares, como a osteoartrite (OA). Um dos fatores de risco para a OA é a obesidade. Além de ser um fator de risco para a OA, a associação entre OA e obesidade pode aumentar a intensidade da dor e das limitações funcionais, devido a uma maior descarga de peso na articulação acometida, com estreitamento do espaço intra‐articular, que pode aumentar a dor articular, rigidez e atrofia muscular. Numa recente metanálise que avaliou o risco para o inicio da OA, reportam que pessoas obesas têm três vezes mais risco de desenvolver OA em relação a indivíduos sem sobrepeso.

O peso excessivo aumenta tanto a pressão quanto a força sobre a articulação, ativa mecanismos de degradação da cartilagem articular, esclerose do osso subcondral e formação de osteófitos e leva ao agravamento da AO. Esses fatores podem influenciar negativamente na qualidade de vida (QV) de idosos obesos acometidos pela doença. A OA por si só ou em conjunto com a obesidade está associada a um maior risco de morbimortalidade e pode reduzir a QV do idoso. Um atributo essencial na saúde do idoso é a sua capacidade funcional, um componente chave para avaliação global da saúde. Além de ser fator de risco para a AO, a obesidade pode agravar sintomas e aumentar o declínio funcional de idosos com OA. Compreender fatores que interferem na capacidade funcional e QV de idosos com AO pode contribuir na formulação de estratégias de prevenção e tratamento. Diante disso, este estudo teve como objetivo comparar a capacidade funcional e a QV de idosos com OA de joelho, obesos e não obesos.

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Mansueto Gomes-Neto, Anderson Delano Araujo, Isabel Dayanne Almeida Junqueira, Diego Oliveira, Alécio Brasileiro, Fabio Luciano Arcanjo

Comparative study of functional capacity and quality of life among obese and non-obese elderly people with knee osteoarthritis

Revista Brasileira de Reumatologia (English Edition), Volume 56, Issue 2, March–April 2016, Pages 126-130

Vamos falar sobre o Aparelho Isocinético

O Aparelho Isocinético é um equipamento conectado a um computador que capta informações de movimento. Leia mais

Dynamic leg length asymmetry during gait is not a valid method for estimating mild anatomic leg length discrepancy

Gustavo Leporace, Luiz Alberto Batista, Raphael Serra Cruz, Gabriel Zeitoune, Gabriel Armondi Cavalin, Leonardo Metsavaht


Anatomic limb length discrepancy (ALLD) has been related to different orthopedic conditions, such as posterior tibial tendon dysfunction and hip osteoarthritis, due to an inadequate distribution of mechanical loads, as well as gait kinematics asymmetries resulted from ALLD have been related to plantar fasciitis, low back pain, and anterior knee pain. On the other hand, some studies have shown that limb length discrepancy (LLD) lower than 35 mm would not have a hazardous outcome in both function and etiology of orthopedic conditions. Khamis and Carmeli suggested that the controversy regarding the role of LLD on orthopedic conditions is related to the poor validity of measurement methods and the several abnormal biomechanical alterations that could be caused by LLD. Although there is no established gold standard method for assessing ALLD, the most accurate and reliable tools used to assess this condition currently involve radiation emission. Also, these methods are subject to minor errors, such as magnification or rotation and may require compliance of the patient to stand still for a long time. Therefore, a radiation-free tool to provide information about the patients’ LLD effects becomes very attractive. Recently, Khamis and Carmeli published a case report on a new promising concept for measuring LLD using a 3D motion analysis. The authors utilized a gait analysis biomechanical model to access dynamic leg length discrepancy (DLLD) and compared the results to ALLD, measured by standing x-ray, with concordant findings. Although 3D motion analysis (3DMA) is a recognized tool to analyze the consequences of LLD on gait parameters so far it has not been validated to determine ALLD. The purpose of this study was to test the validity of dynamic leg length discrepancy (DLLD) during gait as a radiation-free diagnostic screening method for measuring anatomic leg length discrepancy (ALLD). To achieve that purpose, we calculated the correlation and difference between DLLS, acquired by a 3D motion analysis system during gait, and ALLD values, acquired by x-ray scanogram. It was expected that DLLD between hip joint center (HJC) and heel marker (HEE) and HJC and ankle joint center (AJC) in the loading response and single support phase would be a valid strategy, i.e. have high correlation and no significant difference, to measure ALLD. Following the same philosophy, DLLD between HJC and toe marker (TOE) was expected to be a valid strategy to measure ALLD during pre-swing phase, as proposed by Khamis and Carmeli. These hypotheses relied on the presumption of the inverted pendulum model during support phase of gait and the movement of the distal markers in relation to the ground during each gait phase.


2.1. Participants

Thirty-three subjects (17 females) with average age, mass and height of 43.0 ± 22.1 years, 71.2 ± 18.3 kg, 169.2 ± 11.8 cm, respectively, participated in the study. All subjects presented rearfoot strike during gait. The inclusion criteria were all subsequent subjects seen by the same Orthopedic Surgeon (L.M.), with lower-limb and/or lower back complaints that on clinical examination the LLD ranged from 0 to 2 cm. This range was chosen because the prevalence of LLD of 2 cm or less has been reported to be higher than 99% on the general population. ALLD was assessed by measuring the length of the femur and tibia by the scanogram method as described in Sabharwal and Kumar. All participants did the digital radiographic exam (Model DR-F, GE Hualum Medical Systems) in the same radiology laboratory and measurements performed by the same Radiologist. The exclusion criteria were history of lower limb fractures, realignment or joint reconstruction surgery, radiologic scoliosis 10° or higher according to Cobb angles, pregnancy, discomfort or inability to perform the exams accordingly. The study was approved by the local institutional Ethical Committee for Human Experiments. All participants were informed about the purpose of the study and risks and consented before participation.

2.2. Procedures

Initially, a standing trial in a static position was collected for each subject to individualize marker position, calculate joint centers and segment positions during walking. Then, participants performed a barefoot walk along an eight meters long walkway. Subjects were instructed to walk at their self-selected speed performing six trials along the walkway, and the last three gait cycles for each lower limb captured by the motion analysis system were used for analysis.

2.3. Data reduction

Kinematic data were collected using an 8 high-speed cameras motion analysis system (Vicon, Oxford, UK) with a sample rate of 100 Hz. Markers, segments and joint centers were set according to Plug-In Gait recommendations. Data were filtered by a fourth order zero-lag low pass Butterworth filter, with a cut-off frequency of 6 Hz, and Euler angles of lower limbs were calculated using Nexus software (Vicon, Oxford, UK). To determine stance and swing phases of each cycle, the Foot Velocity Algorithm was used. Dynamic leg length (DLL) was defined as the effective length of the lower limb, measured by three variables, according to Khamis and Carmeli: (i) the distance from the HJC to the HEE (HJC-HEE); (ii) the distance from the HJC to the AJC (HJC-AJC); (iii) the distance from the HJC to the TOE (HJC-TOE). Dynamic leg length discrepancy (DLLD) was measured by the difference between functional leg lengths of both sides. Predictor variables were the peak and average DLLD (HJC-HEE; HJC-AJC; HJC-TOE) during loading response, single limb support, and pre-swing phases of gait. Interest variable was ALLD.

2.4. Data analysis

Pearson correlation coefficients were calculated to determine the associations between predictors (peak and average DLLD, in cm, in the three gait phases described above) and interest (ALLD) variables. Predictor variables that presented significant correlations with coefficient higher than 0.4 were included in a multiple linear regression with ALLD as output. Stepwise approach was used to find the best model among all predictor variables possibilities, using the Akaike information criterion (AIC) to include variables into the models. To assess the fitting of the model, a leave-one-out cross-validation procedure was used. All coefficients of the models were calculated using data from 38 subjects, and data from the subject left out of the analysis were used to simulate ALLD. Paired Student t-tests were applied to compare the differences between each predictor variable and ALLD. To estimate the magnitude of the difference between groups, Cohen’s d effect size was calculated. Cohen classified effect sizes as small (d < 0.2), medium (0.2 < d < 0.5), and large (d > 0.8). Significance level was set at 5%. Statistical significance was set at α = 0.05. All statistical analyses were performed using MATLAB (version 8.6.0, The Mathworks, USA).


The subjects showed a mean ALLD of 1.0 ± 0.7 cm. There were no significant correlations between predictors and interest variables (Table 1, Table 2). As no predictor variable showed significant results, no multiple linear regression models were possible to be developed.

table 1 table2

Peak DLLD values presented significant difference from ALLD in loading response (Peak HJC-TOE), single leg support (Peak HJC-AJC and Peak HJC-TOE) and Pre-Swing (Peak HCJ-HEE), although all effect sizes had medium values (Table 3). There were no significant differences between average DLLD and ALLD in any phase of gait. All effect sizes values were lower than 0.8 (Table 3).

table 3


The aim of this study was to test the validation of a radiation-free method to predict anatomic leg length discrepancy (ALLD). The results of our study did not support our initial hypothesis. There were no significant correlations between DLLD measures with ALLD during the different support phases of gait. As the coefficients of correlation were not significant, no regression equation was developed to predict ALLD from dynamic leg length asymmetries. This result suggests DLLS during gait is not a valid metric to predict ALLD. On the other hand, most of paired t-tests did not reveal differences between all DLLD measures and ALLD, what may explain the similar value found by Khamis and Carmeli in their case report. Although gait analysis is a valid and reliable tool to calculate joint angles and moments, such alterations may occur to compensate ALLD, in order to minimize the deleterious effect of LLD and decrease displacement of center of mass due to the limb discrepancy. Pelvic elevation of the longer leg in single limb support phase of gait is a kinematic variable that has been found in patients with different ALLD magnitudes. Alterations in sagittal plane as hip, knee and ankle flexion were found in some studies. Despite the lack of validity of DLLD to predict ALLD, there are evidences of association between the magnitudes of limb discrepancy and compensatory strategies during gait. This could explain the negative correlation coefficients between predictor and interest variables found in the present study. Therefore it is recommended further research to determine if joint angles in the sagittal and frontal planes could provide a more accurate prediction of ALLD. Our study included only subjects with mild discrepancy so, it is acceptable that our negative results may be related to the lack of significant biomechanical alterations associated to leg length asymmetry and it is not possible to predict accurately ALLD without image exams. The purpose of this study was to test the validation of DLLD during gait to predict ALLD with a radiation free strategy, so we decided to include all subjects with ALLD lower than 2 cm to be more realistic with clinical practice. A possible strategy to deal with that is developing non-linear models, as neural networks to predict ALLD to take into consideration these subjects without clinically significant asymmetries. Further studies should include subjects with higher asymmetry to develop a more general model to screen subjects with significant ALLD.


The data analysis revealed no correlation between anatomic leg length discrepancy and dynamic leg length discrepancy, measured by a 3d motion analysis. Although the dynamic leg length discrepancy during gait analysis is an interesting tool to depict movement asymmetries, it was not proved to be a valid method to predict ALLD in subjects with mild limb discrepancy. So, DLLD during gait should not be used as a screening tool to predict ALLD in orthopedic injured patients.

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Condromalácia patelar

Condromalácia patelar é o amolecimento e degeneração da cartilagem da patela, decorrente do uso excessivo, trauma direto ou indireto decorrente de alteração biomecânica da articulação patelo femoral, representando uma causa comum de dor anterior no joelho.

O tratamento visa o fortalecimento do músculo que está em desequilíbrio, a fim de melhorar a disfunção e o reequilíbrio muscular. Assim, o paciente passa por tratamentos e medidas que fortaleçam a musculatura do joelho e quadril. O trabalho da AF Fisioterapia é realizar junto com o paciente exercícios para a região, com o objetivo de melhorar a função e encorajar o paciente ao retorno da prática esportiva.

Fisioterapia especializada

A Clínica AF Fisioterapia foi idealizada com o intuito de proporcionar um tratamento personalizado, respeitando a individualidade de cada paciente. Está sentindo dor no quadril ou joelho? Procure nossos especialistas qualificados e conheça o nosso protocolo de atendimento baseado em evidências:

1. Avaliação Clínica Detalhada: o corpo clínico formado por fisioterapeutas avaliam de forma global e funcional cada, colhendo todos os dados importantes para início do tratamento:

2. Avaliação Cinemática: caso seja necessário, o paciente pode ser encaminhado para avaliação com sistema 2D que permite analisar quaisquer alterações na força ou funcionalidade pode ser utilizado;

3. Protocolo Exclusivo de Atendimento: foco no alinhamento biomecânico possibilitando maior qualidade de vida.


Síndrome femoropatelar, via Instituto Trata

O que é?

A Síndrome da Dor Femoropatelar (SDFP) é ocasionada por um desequilíbrio biomecânico, que atinge a articulação do joelho, mais especificamente a articulação entre o fêmur e a patela. Acomete até 25% da população, sendo mais comum em mulheres sedentárias e indivíduos com grau de treinamento elevado.

Diversas causas podem estar relacionadas com a SDFP como: largura excessiva da pelve, joelho valgo, fraqueza muscular dos músculos do quadril e da coxa, patela alta, insuficiência ligamentar, dentre outros.


Dor na região anterior do joelho, ao subir e descer escadas, ao agachar e saltar, após longo período sentado (sinal do cinema), estalos ao andar e correr, sensação de areia dentro da articulação.

Diagnóstico e exames

Um exame físico deve ser realizado pelo fisioterapeuta especializado ou médico a fim de avaliar prováveis insuficiências de partes moles, acometimento de estruturas articulares, além de fatores que afetem as força e o alinhamento articular.

O tratamento depende da causa da dor no joelho, sendo geralmente conservador, baseado em técnicas de Fisioterapia. A fisioterapia específica visa melhorar o deslizamento da patela sobre o sulco troclear no fêmur, utilizando exercícios de fortalecimento muscular e correção biomecânica. Os resultados das sessões de fisioterapia vão depender das características individuais de cada paciente.

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